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Objectives/Hypothesis Despite careful selection processes, residency programs face the challenge of training residents who fall below minimal performance standards. Poor performance of a resident can endanger both patient safety and the reputation of the residency program. It is important, therefore, for a program to identify such residents and implement strategies for their successful remediation. The purpose of our study was to gather information on evaluation and remediation strategies employed by different otolaryngology programs. Study Design Cross-sectional survey. Methods We conducted a national survey, sending a questionnaire to the program directors of 106 otolaryngology residency programs. We collected information on demographics of the program, identification of problematic residents, and remediation strategies. Results The response rate was 74.5%, with a 2% cumulative incidence of problematic residents in otolaryngology programs during the past 10 years. The most frequently reported deficiencies of problematic residents were unprofessional behavior with colleagues/staff (38%), insufficient medical knowledge (37%), and poor clinical judgment (34%). Personal or professional stress was the most frequently identified underlying problem (70.5%). Remediation efforts included general counseling (78%), frequent feedback sessions (73%), assignment of a mentor (58%), and extra didactics (47%). These remediation efforts failed to produce improvement in 23% of the identified residents, ultimately leading to their dismissal. Conclusions The apparent deficiencies, underlying causes, and remediation strategies vary among otolaryngology residency programs. Based on the results of this survey, we offer recommendations for the early identification of problematic residents and a standardized remediation plan. Level of Evidence NA Laryngoscope, 2015

Objectives/Hypothesis Evidence shows a positive association between quality of surgical training received and patient outcomes. Traditionally, improved patient outcomes are linked with increased operative volume. However, generalizing this finding to surgeons in training is unclear. In addition, reduced exposure due to work-hour restrictions calls for alternative methods to determine the quality of training. The purpose of this study was to identify the indicators of high-quality training by surveying the trainees and trainers. Methods A questionnaire was developed based on input from faculty and previous studies. The survey was divided into three sections asking about the indicators of quality training, methods to measure them, and interventions for improvement. The questionnaire was administered to program directors (PDs) and senior residents of otolaryngology training programs nationwide. Results The strongest indicators of quality training that were agreed upon by both residents and PDs were having faculty development as an ideal trainer while having a balanced level of supervision and independence, logbooks for exposure to volume and variety of pathology, continuous evaluation and provision of feedback. However, structured teaching, simulation-based training, and trainee exam scores failed to reach an agreement as a metric of high-quality surgical training. Conclusion Measuring quality of a residency training program is imperative to produce competent surgeons and ensuring patient safety. The results of this study will help the residency programs to better train their residents and improve the quality of their teaching. Level of Evidence N/A. Laryngoscope, 2015

Objectives/Hypothesis The Difficult Airway Response Team (DART) was implemented in July 2008 to address emergent difficult airway situations. The main objective of this study was to highlight the unique role and skill set that otolaryngologists bring and their impact on patient outcomes. Study Design Retrospective review of prospectively collected data from the hospital's airway registry. Methods We collected data on demographics, airway characteristics, airway management techniques used by each specialty, and clinical outcomes (such as cricothyrotomies) for patients for whom a code was activated between July 2006 and June 2010. We compared data between pre- and post-DART cohorts and between DART and non-DART patients using a matched case-control approach. Results Of the 2,826 codes, 90 patients required DART management between July 2008 and June 2010. Body mass index, cervical spine injury/fixation, history of difficult airway, head and neck mass, and oropharyngeal and/or supraglottic angioedema were identified as significant predictors for DART activation. Forty-nine (60%) patients' airways were secured by anesthesiologists, 30 (36%) by otolaryngologists, and three (4%) by trauma surgeons. Otolaryngologists were able to use specialized techniques such as Holinger and Dedo laryngoscopes to significantly decrease the number of cricothyrotomies from seven (0.73%) pre-DART implementation to four (0.21%) post-DART implementation. Conclusions Otolaryngologists were able to decrease the need for cricothyrotomies using specialized techniques for patients with difficult airways. Otolaryngologists bring a special skill set to the DART that is beyond the scope of anesthesiologists and trauma surgeons and that can improve patient outcomes by preventing unnecessary emergency surgical airways. Level of Evidence 2b Laryngoscope, 125:640–644, 2015

OBJECTIVES/HYPOTHESIS: To measure the effect of distractions on the operative performance and analyze if practice and experience are the factors that can help to overcome the distractions. STUDY DESIGN: Prospective observational study. METHODS: Ten postgraduate year (PGY) 2-6 residents and two faculty members from Johns Hopkins' otolaryngology department were recruited and asked to deepen the dissection at the sinodural angle on the Voxel-man mastoidectomy simulator. They were asked to perform the task under four conditions: 1) no distractors, 2) differentiation and counting of a specific alarm sound among different sounds played in the background while performing the surgical task, 3) simultaneous performance of simple arithmetic task of moderate difficulty, and 4) simultaneous performance of the task with both sets of distractors combined. RESULTS: Time taken for the task (P = .02) and error scores (P = .002) increased under the third and fourth conditions. The ability to multitask and response to surgical and cognitive tasks improved with increasing level of experience of the participants. CONCLUSIONS: Distractions lead to impaired dexterity and an increase in the incidence of errors. However, experience and deliberate practice can help achieve the ability to multitask without compromising the operative performance. LEVEL OF EVIDENCE: NA Laryngoscope, 2014. Keywords: Driver distraction; Language: en

Objectives/Hypothesis To examine the effects of a learner-centered educational curriculum for Johns Hopkins otolaryngology–head and neck surgery residents in improving their otolaryngology training examination (OTE) scores. We hypothesized that trainees who attend a learner-centered program demonstrate improved performance on OTEs. Study Design Prospective longitudinal study. Methods In September 2008, a resident-designed educational curriculum was implemented to better prepare residents for their OTE. These mandatory sessions, led by faculty members, were held for an hour every week, during in which residents were tested on their knowledge of high-yield topics. Residents were expected to be prepared on pathophysiology, diagnosis, and treatment of the selected diseases. In 2011, residents were given responsibility to lead these sessions. OTE scores from 2002 to 2012 were analyzed to see whether there was any improvement after the implementation of this curriculum. Results Clustered linear regression analysis revealed significant improvement of OTE scores with subsequent interventions. During a 3-year period (2009–2011) after the first intervention, there was a significant increase (P = .01) of 0.69 in mean national and 0.78 in mean group stanine scoring. Similarly, after the second intervention in 2011, a further increment of 1.36 in mean national and 1.58 in mean group stanine scoring was seen (P = .001). Conclusions Residents OTE stanines improved significantly after the implementation of a learner-centered educational curriculum. This finding suggests that trainees are able to perform better when involved in planning and implementing the educational curriculum. Level of Evidence NA Laryngoscope 124:2262–2267, 2014

Objectives/Hypothesis To develop and assess the feasibility of a new standardized protocol to guide tracheostomy decannulation. Study Design Descriptive review of quality improvement project. Methods A quality improvement project was conducted in the inpatient setting of a tertiary urban academic hospital. Adult patients who had received a tracheostomy and for whom the indication for tracheostomy had resolved were included. A multidisciplinary task force reviewed input from clinicians caring for tracheostomy patients and developed a protocol for screening, capping, and decannulation. The primary outcome measured was successful decannulation. Results Fifty-seven patients were screened for a capping trial over a 12-month period; 54 were capped. Six patients were lost to follow-up. Fifty patients passed the capping trial, and all 50 were decannulated successfully. When decannulation was pursued in one patient who had twice failed the screening criteria and subsequent capping trials, the patient failed decannulation and ultimately required reintubation for the management of secretions. The screening tool had high sensitivity (90%) and positive predictive value (100%) for successful decannulation. Additionally, the number of reported patient safety concerns decreased from seven in the 6 months preceding implementation of the program to one report in the 6 months after implementation. Conclusion The new tracheostomy capping and decannulation protocol assisted in predicting both successful and failed decannulation. Although several patients failed certain capping criteria initially, the protocol stipulated modifications of care that enabled successful decannulation. The screening tool had high sensitivity and promoted communication, standardization of practice, and patient safety. Level of Evidence 2b. Laryngoscope, 124:1794–1800, 2014

Objectives/Hypothesis The purpose of this study is to compare faculty and trainees' perceptions of their mentorship experience in otolaryngology training programs in order to identify areas where improvements could yield more productive mentorship. Study Design Cross-sectional survey design. Methods Residents and faculty from three otolaryngology–head and neck surgery programs were surveyed regarding their perceptions of their mentoring relationship. Trainees were asked about the characteristics of their mentorship experience. Separately, faculty were asked to describe their mentorship relationship, available resources to provide effective mentorship, and to identify areas in which formal training would improve their mentoring skills. Results Forty-eight trainees (72%) and sixty-one faculty members (73%) completed the survey. Ninety percent of residents meet with their mentors at least twice a year. Faculty and residents (> 80%) agreed that career planning was the most commonly addressed topic in mentorship sessions. However, faculty and residents differed in their perceptions of providing mentorship in other areas including clinical judgment (P = 0.003). The majority of faculty (56%) felt that formal mentorship training would improve their mentorship skills. While 95% of mentees agreed that their mentor is accessible, only 46% of faculty believed they have enough time to dedicate to mentoring (P

Objectives/Hypothesis: To assess whether practice on a virtual-reality (VR) temporal bone simulator improves acquisition of technical skills in mastoid surgery. Study Design: Prospective blinded study. Methods: Using a previously validated objective structured assessment of technical skills (OSATS) tool, performance was assessed in 12 residents for two tasks of cortical mastoidectomy: 1) identifying and defining the tegmen and 2) defining the sigmoid sinus and sinodural angle. These surgical tasks were chosen as key steps in mastoid dissection because they were of intermediate complexity. Videos of virtual dissections were captured at baseline and again after practicing each task four to six times. Results: OSATS scores for the tegmen task increased from 2.125 ± 1.25 to 3.1 ± 0.85 (P = .026), whereas for the sigmoid task scores increased from 2 ± 0.45 to 2.75 ± 1.125 (P = .0098). The time to complete the tasks decreased from 8.37 ± 4.78 minutes to 5.39 ± 3.06 minutes (P = .018) for the tegmen task and from 8.99 ± 6.7 minutes to 8.68 ± 5.98 minutes (P = .594) for the sigmoid task. There was a decline in number of injuries from 0.5 ± 1.5 to 0 ± 0.5 (P = .594) for the tegmen task and from 2.5 ± 4 to 0.5 ± 1 (P = .029) for the sigmoid task. Conclusions: Technical skills in mastoidectomy surgery can be acquired during even brief practice on the VR temporal bone simulator. It is anticipated that longer periods of practice presented within the fundamentals of comprehensive curriculum will facilitate procedural learning. Further studies are required to elucidate evidence of transference of these skills to the operating room and to procedures of greater complexity.

Objectives/Hypothesis: Previous studies have identified a predominant learning style in trainees from different specialties, more recently in otolaryngology residents. The purpose of our study was to determine a predominant learning style within otolaryngology fellowships and to identify any differences between otolaryngology fellows and residents. Study Design: We conducted a survey of otolaryngology fellows at 25 otolaryngology fellowship programs accredited by the Accreditation Council for Graduate Medical Education. Methods: We emailed Kolb's Learning Style Index version 3.1 to 16 pediatric otolaryngology (PO) and 24 otology/neurotology (ON) fellows. This index is a widely used 12-item questionnaire. The participants answered each item in the questionnaire as it applied to their preferred learning style: accommodating, converging, diverging, or assimilating. Results were then analyzed and compared between each subspecialty and the previously reported preferred styles of otolaryngology residents. Results: Ten PO and 20 ON fellows completed the survey, with an overall response rate of 75%. PO and ON fellows (60% of each group) preferred a learning style that was “balanced” across all four styles. For ON fellows, 35% preferred converging and 5% preferred accommodating styles. For PO fellows, converging and accommodating styles accounted for 20% each. Conclusions: It was previously reported that 74.4% of otolaryngology residents prefer either converging or accommodating styles. We believe that the fellowship training environment calls for fellows to use more than one learning style to become proficient physicians, hence the trend toward potentially developing a balanced style when at this level.

Objectives: To develop a valid and reliable tool for an objective structured clinical examination (OSCE) on hoarseness. To pilot-test the feasibility by assessing residents' clinical skills in various core competencies while assessing hoarseness on a standardized patient (SP). Study Design: Educational tool development. Methods: The OSCE checklists were developed using modified Delphi technique after obtaining feedback from faculty involved in providing care to hoarseness patients. SP-based and rest stations were created to assess clinical skills. Twelve Otolaryngology–Head and Neck Surgery residents participated in the study. Video recordings of residents' performance and their written documentation were rated by faculty members. Results: The OSCE that we developed is a valid method of assessing residents' clinical skills for evaluating hoarseness. Senior residents performed better in all of the tasks such as obtaining history and performing a physical exam on an SP, ability to perform flexible laryngoscopy on a mannequin, and interpretation of radiologic findings. Internal consistency assessed by Cronbach's alpha as measure of inter-item reliability was 0.92 for laryngoscopic station and 0.95 for radiology station. Conclusions: This OSCE can be effectively used for the objective assessment of clinical competency in hoarseness. Our pilot study evaluated multiple competencies on a single occasion, including medical knowledge, patient care, professionalism, and communication and interpersonal skills. Clinical competence in history taking, physical examination, flexible fiber-optic laryngoscopy, and ability to interpret radiologic findings improved with increasing year of training. This OSCE provides targeted assessment of practice-based learning and feedback for improvement of clinical performance. Laryngoscope, 2010

Objectives: To evaluate the reliability and validity of the assessment tool for endoscopic sinus surgery when used in the operating room for in-training assessment of operative competency; to identify the tasks that may serve as the best indicators for overall surgical performance. Study Design: Cross-sectional validation study. Methods: We implemented the global and checklist parts of the endoscopic sinus surgery (ESS) assessment tool to evaluate the surgical skills of 13 Otolaryngology–Head & Neck Surgery residents (PGY 1–5) in the operating room over a period of 15 months. Rhinology faculty scored residents' performance of every step of ESS at the end of each procedure using a previously validated tool. Construct validity was calculated by comparing scores across training levels (using analysis of variance [ANOVA]). Regression analysis was performed to identify tasks on the ESS checklist that most strongly correlated to the overall surgical performance. Results: Construct validity was demonstrated with senior residents performing better than junior residents. Average checklist and global scores improved with the number of days on rhinology rotation. “Identification of uncinate and boundaries” was found to be the strongest predictor of overall surgical performance. Conclusions: The results indicate that this evaluation tool is a reliable and valid instrument for the assessment of surgical competency in the operating room. It can be used to identify weak areas of performance for which additional training may be required early in the rotation/training. Laryngoscope, 2010

Objectives/Hypothesis: To identify the barriers faced by otolaryngology program directors as they implement competency-based education and assessment and to identify preferred approaches to meet these challenges as suggested by program directors. Study Design: A national survey of otolaryngology–head and neck surgery program directors. Methods: We developed a 20-item questionnaire that was distributed to 102 otolaryngology program directors through SurveyMonkey. Nonrespondents were reminded by follow-up email and phone calls. Results were analyzed by descriptive statistical analysis. Results: A total of 88 (86%) program directors responded to the survey. There was a marked discrepancy between the income received and time spent performing the duties of the program director. Program director workload was recognized as the most important barrier to the implementation of competency-based education. Creating a practical clearinghouse of existing and emerging assessment tools was given the highest rating among the approaches to meet the challenges faced by program directors. Conclusions: Program directors in otolaryngology do not have sufficient financial support, protected time, and personnel to fulfill their administrative and educational responsibilities. They should be provided with additional institutional assistance to help them achieve the goals of the Accreditation Council for Graduate Medical Education outcome project.

Objectives/Hypothesis: To establish milestones toward achievement of surgical competency by using an objective assessment tool designed to measure the development of mastoidectomy skills in the operating room (OR). Study Design: Prospective longitudinal validation study. Methods: Fifty-six evaluations were conducted in the OR on nine otolaryngology residents from PGY (postgraduate year) 2 to PGY 5 over a period of 3 years. Technical performance was measured over time using a task-based checklist developed for assessment of mastoidectomy skills. Results: Three sets of technical milestones represented achievement of competency for progressively more complicated procedural steps: the first set was achieved after a mean of 6 ± 4.3 cases, the second set after 9 ± 6.7 cases (range of mean = 8–10 cases), and the third set after 13 ± 6.4 cases (range of mean = 12–14 cases). Conclusions: The acquisition of mastoidectomy skills can be integrated into surgical teaching in the OR, and this approach yields information that can aid individual skill development and program improvement. The identification of milestones in particular can help establish training benchmarks toward achievement of competency and in identifying trainees in need of remediation.

Objectives/Hypothesis: Kolb portrays four learning styles depending on how an individual grasps or transforms experience: accommodating, assimilating, diverging, and converging. Past studies in surgery, medicine, and anesthesia identified the predominant learning style in each of these specialties. The prevalence of different learning styles and existence of a predominant style, if any, has not been reported for otolaryngology residency programs. The purpose of our study was to determine if otolaryngology residents have a preferred learning style that is different from the predominant learning styles reported for other specialties. Study Design: We conducted a survey of the otolaryngology-head and neck surgery residents at two residency programs. Methods: Kolb's Learning Style Index (LSI) version 3.1 was administered to 46 residents from Johns Hopkins University and Kansas University Otolaryngology–Head and Neck Surgery programs. LSI is a widely used 12-item questionnaire, with each item followed by four options. The subjects graded the options depending on how the options applied to them. Results: Forty-three otolaryngology residents completed the survey, with a response rate of 93.47%. The predominant learning style was converging (55.81%) followed by accommodating (18.61%), accounting for the learning styles of 74.42% of the total population. There were only 13.95% assimilating and 6.98% diverging learning styles. Two residents (4.65%) had their preference balanced across four learning styles. Conclusions: The predominant learning styles in otolaryngology were converging and accommodating, accounting for three fourths of the population. It would be desirable to modify our curriculum in a way that will optimize and facilitate learning.

Objectives/Hypothesis: 1) Assess current status of operative competency assessment and feedback among US Otolaryngology residency programs. 2) Evaluate correlations between assessment or feedback tools and remediation. Study Design: Survey of Program Directors. Methods: The survey was sent to 100 Program Directors inquiring about program size, mode of feedback, assessment tools, surgical portfolios, remediation, and number of residents requiring remediation in past 5 years. Associations between assessment questions and remediation (yes or no) were statistically assessed with the χ2 goodness-of-fit test. For more complicated analyses, multiple logistic regression models were created to assess predictors of the binary outcome of radiation. Results: Among 72 respondents, subjective evaluations are used by 95.8% (69 of 72). Formative feedback after cases is used by 38.9% (28 of 72). Summative feedback at end of the rotation is done by 57.0% (41 of 72). Objective Structured Assessments of Technical Skills is used by 15.3% (11 of 72) of programs, most are large on the basis of number of residents or faculty or both. Operative portfolios are kept by 48.6% (35 of 72) of programs. The percentage of programs with mechanisms for remediation is 41.7% (30 of 72). Similarly, of the programs who responded to the remediation question, the percentage with at least one resident requiring remediation is 37.5%. Programs who report at least one resident remediation are statistically more likely to have a remediation mechanism in place (75% vs. 27.5%; P

Introduction: Percutaneous dilation tracheotomy (PDT) is now an accepted alternative to surgical tracheotomy in certain patients. We began performing these procedures in 2000 and use it regularly in select intensive care unit patients requiring prolonged intubation and mechanical ventilation. Materials and Methods: A retrospective chart review of consecutive PDTs performed in the Department of Otolaryngology-Head and Neck Surgery at the John Hopkins Hospital between 2002 and 2005 was undertaken. Procedural and postoperative complications in an earlier group were compared with those in the later group for both frequency and severity. Results: Three hundred eighteen PDTs were performed on intensive care patients during this time period. All were performed using the Ciaglia method and the Cook Blue Rhino (Cook Medical Products, Bloomington, IN) set under direct bronchoscopic visualization. In group A (first 159 patients), there were a total of 12 complications (7.5%), including six cases of perioperative hemorrhage, whereas in group B (second 159 PDTs), there were seven complications (4.4%) with no cases of perioperative hemorrhage. Conclusions: PDT provides an easy and convenient alternative to open tracheotomy (OT) and should be added to the otolaryngologist's armamentarium of surgical airway procedures. The complication rate of PDT is low and similar to that of open operative tracheotomy. However, with experience and the use of strict protocols in both patient selection and PDT procedure, the complication rate can be significantly reduced further both in frequency and severity, making it even safer than an open operative tracheotomy.

Objectives/Hypothesis The goal of our study is to identify the number of Endoscopic Sinus Surgery (ESS) cases required to obtain competency in ESS, using a previously validated assessment tool. Study Design Prospective observational study. Methods Seventeen residents from Johns Hopkins Otolaryngology–Head & Neck Surgery residency program were evaluated as they performed endoscopic sinus surgery in the operating room. Global and checklist parts of the ESS instrument were used for assessment purposes. Items on the tool were grouped into three different milestones for analysis of data (Milestone 1 = Maxillary Antrostomy + Anterior Ethmoidectomy, Milestone 2 = Posterior Ethmoidectomy + Sphenoidostomy, Milestone 3 = Frontal Sinusotomy). Residents were deemed competent if they achieved a minimum score of 3 on a 5-point Likert scale on each step of the surgery. Results A total of 73 evaluations were completed for 17 residents (Postgraduate Level 2–5) by eight evaluators between 2009 and 2011. A 60% probability of achieving competency in performance of all milestones of ESS is obtained with performing 42 ESS procedures and the probability is increased to a 100% with performance of 55 endoscopic sinus surgery procedures. On average it took residents 23 cases to become competent in performance of maxillary antrostomy and anterior ethmoidectomy. Conclusions Our results suggest that it requires 42 ESS procedures to attain a 60% probability of competency in ESS. These results have implications for otolaryngology residency programs when developing curriculum and benchmarks for the training residents. Laryngoscope, 123:2932–2934, 2013

expertise when faced with difficult patients, or may find themselves wondering what their colleague would do when faced with a difficult problem. This miniseminar is designed to review advanced concepts that have more universal and practical applications for all otolaryngologists who care for rhinologic problems. In this entertaining and informative miniseminar, a panel of experts will discuss challenging cases, which demonstrate techniques and convey medical knowledge that will benefit all practitioners. The goal will be to educate practitioners on aspects of advanced care that can be applied by nearly any otolaryngologist. The tips, tricks, and pearls that will be covered will include applied allergy and immunology, infectious disease management, anatomic keys, technological advances to improve surgery, and ways to manage complications. Specific cases will include complicated allergic/inflammatory disorders, infectious problems, complicated nasal polyposis, encephaloceles, skull-base tumors, and others. Of the needs identified by the AAO membership for 2010, this miniseminar will cover infectious disease and antibiotic coverage, patient safety, and surgical techniques and demos. EDUCATIONAL OBJECTIVES: 1) Discuss methods of treating advanced allergic, immunologic, and infectious disorders in rhinology. 2) Review key sinus and skull base anatomy, and how to exploit these in surgery. 3) Discuss how new medical and technological advances are being applied to rhinology patients.